A patient that the court called "Joseph '0'" suffered from paranoid schizophrenia. For 20 years he took the drug Stelazine and was able to function "quite well." At his brother's request, Joseph's psychiatrist switched his medication to Risperdal. Soon after the change, Joseph stopped taking his medication, and his mental condition deteriorated, resulting in an admission to a psychiatric center. A psychiatrist at the center found him to be oriented to time and date, but also to be psychotic, unable to focus on any particular subject, and prone to incidents of bizarre and disruptive behavior. Further, he found Joseph to be cooperative with the staff, except with regard to the issue of medication. Joseph steadfastly refused to take any drugs, believing that his schizophrenia was cured following prolonged exposure to the sun.
The patient believed that his schizophrenia had been cured following exposure to the sun.
The psychiatrists at the center treating Joseph put together a treatment plan, then sought a court order to administer antipsychotic drugs to Joseph against his will. Joseph testified at the hearing, where he demonstrated an understanding of his medical condition and history. However, his answers were not always responsive and he demonstrated a mistrust for his doctors whom he felt were trying to sell him medication he did not need. He testified that he would rather be confined to an institution rather than be free and forced to take antipsychotic medication. The court held that the hospital had failed to demonstrate by clear and convincing evidence that Joseph lacked the capacity to make his own decisions concerning psychiatric treatment. The hospital appealed.
Holding: The lower court's decision was affirmed. The court found that it was a "close question" as to whether Joseph had the capacity to refuse medication. However, given the "high standard of proof necessary to establish incapacity," as well as the trial court's opportunity to witness Joseph's testimony in person, the court held that it would defer to the lower court's findings and abide by its decision.
| Robert Sherman, Esq. Greenberg Traurig LLP |
Attorney Sherman comments: This case demonstrates the high threshold courts will set before sanctioning intrusions into the area of constitutional rights. Since the 1970's, courts have recognized a fundamental constitutionally-based right to be free from unwanted bodily invasions. That right is particularly significant in conjunction with the administration of anti-psychotic medication which, in addition to its therapeutic benefits, exposes the patient to the potential of serious side effects.
The fundamental freedoms guaranteed to all citizens by the Bill of Rights applies as well to the mentally ill, who do not lose their constitutional rights by reason of their handicapped condition. Consequently, recipients of health care are not only to be treated as equal citizens, they are also entitled to the same freedom of choice attendant to that citizenship.
With respect to treatment decisions, the law recognizes that freedom of choice includes not only the right to choose from among available treatment procedures, but also the right to refuse treatment, even one that may be highly beneficial. The origin of this right is rooted in the doctrine of informed consent, which requires the consent of the patient before any psychological or medical treatment can be administered lawfully. Three critical elements are necessary to establish conformed consent:
a) It must be preceded by disclosure of adequate information;
b) It must be voluntarily given; and
c) The consenting individual must be competent.
When those elements are present, the law does not require that the ultimate decision be a wise one. Our society is founded on a respect for a persons right to be an individual, which allows such choices to be made. For example, a person has a right to refuse amputation of a gangrenous leg, even though death is the likely result. The law's requirement is not that the decision necessarily serve the patient's best interests, but only that the person's ability to make that decision not be so impaired that it threatens his or her safety or welfare. That concept is known as competency.
In Joseph O., the appellate court's decision to uphold the lower court's finding of competency is troubling. Two psychiatrists, including the patients treating psychiatrist, testified that the patient could not make "reasoned decisions regarding his treatment." No expert testified on behalf of the patient to rebut that testimony. Moreover, the patient himself displayed a patent lack of appreciation for his own medical condition when he testified that "his schizophrenia has been cured following his prolonged exposure to the sun."
The court's decision implicitly recognized that competency is not a static determination, as well as the importance of respecting the rights of the individual. While the patient clearly did not have a fully informed understanding of his problem, what appeared significant to the court was that the patient understood his medical options. When faced with the choice of being institutionalized without anti-psychotic medication, or being released in the community and required to take the medication, he clearly and unequivocally expressed a preference for the former. The court did not view the patient's individualized choice as so unreasonable that it should not be respected.
| Lawrence Kirstein, M.D. Psychiatrist The Forensic Panel |
Dr. Kirstein comments: Paranoid schizophrenia patients have a high rate of medication noncompliance. Schizophr Bull, 1994, 20:297-310. While part of an explanation can be attributed to both short term and long term side effects of the antipsychotic medications, another critical element relates to the core paranoid construct: "I am not sick, the world is sick and against me." J Clin Psychiatry, 1998, 59 supp:21-25. The treating physician can lessen compliance problems by switching the schizophrenic patient form short acting oral drugs to long acting injectable drugs. Fluphenazine (Prolixin) and Haloperidol (Haldol) are often recommended for this reason. One injection of each of these depot medicines may last two to four weeks.
In this particular case, the patient was compliant with long term oral antipsychotic medication. Since the positive effect of antipsychotic medication lasts for a number of weeks following the stopping of drugs, it would not be expected that changing pills would cause a rapid deterioration in his mental state with a sudden resurgence of paranoid thinking. However, change per se can disrupt the routine of a chronic schizophrenic.
Waiting may make the court's decision clearer.
In this unfortunate case, despite the best intentions of family and physician, the change caused sufficient disruption to cause medication noncompliance. In this case, psychosis and paranoia prompted the request to medicate against the patient's will. However, the patient's awareness of the consequences of prolonging hospitalization coupled with an absence of reported dramatic changes in sleep or appetite provided sufficient grounds to justify the patient's position.
Although some paranoid schizophrenic patients remain at a plateau of deteriorated functioning, many more continue to show an escalation of bizarre symptoms or deterioration off medications, as the beneficial effects of the prior medications dissipate. The issue of the patient's competence to refuse medication should be revisited then; behavioral and cognitive symptoms may make the court's decision to medicate over objection much clearer.
